The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions.

A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using statistics.

The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent (n = 1116/1860, 60%) than for conservative management (n = 744/1860, 40%; P < .001). Interrater agreement regarding the final management decision was "slight" ( = 0.12; 95% CI, 0.09–0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases.

Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.

机械血栓切除术联合或不联合静脉溶栓治疗后持续性远端闭塞患者的最佳治疗方法仍不清楚。我们试图评估持续性远端闭塞决策的可变性和一致性。

60 个病例的组合被发送给具有不同背景和经验的临床医生。受访者被问及是否考虑保守治疗或抢救治疗（支架取出器、抽吸或动脉内溶栓）作为治疗选择，以及是否愿意将患者纳入随机试验。使用统计数据评估一致性。

31 名医生（8 名血管神经科医生和 23 名介入神经放射科医生）回答了电子调查。采取挽救治疗的决定 ( n = 1116/1860, 60%) 比保守治疗 ( n = 744/1860, 40%; P < .001)更频繁。关于最终管理决策的评估者间一致性“轻微”（= 0.12；95% CI，0.09–0.14），并且当根据背景、经验和专业对临床医生亚组进行研究或根据水平对病例进行分组时，这种一致性并没有改善的闭塞。在延迟重新询问时，29 名受访者中有 23 人 (79.3%) 在至少 20% 的案件上不同意自己的观点。 1860 起案件中，受访者愿意参与审判，其中 1295 起（69.6%）。

对于机械血栓切除和静脉溶栓后持续性远端闭塞患者的最佳处理，人们并没有达成一致。有足够的不确定性来证明专门的随机试验的合理性。